Looking Ahead to Issues Affecting Geriatric Care in 2014
Dr. Stefanacci served as a CMS Health Policy Scholar for 2003-2004, is an associate professor of health policy, University of the Sciences, and a Mercy LIFE physician, Philadelphia, PA; and is chief medical officer, The Access Group, Berkeley Heights, NJ
Dr. Spivack is the founder of the Connecticut Geriatrics Society, and is on the medical staff, Greenwich Hospital, Greenwich, CT.
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The year 2014 is sure to be significant for geriatric healthcare providers for a number of reasons. The vast majority of the issues affecting geriatric care providers fall into one of three categories: (1) insurance expansion; (2) reimbursement changes; and (3) adjustments to care delivery. President Barack Obama signed into law the Patient Protection and Affordable Care Act (ACA)1 more than 3 years ago. While many of its provisions have already been put into operation, the core of ACA will not take effect until 2014. This law signals a major shift in how we practice, which was largely established in the 1990s. During this time, most geriatric care providers were seeing new Medicare beneficiaries, some of whom would just be gaining coverage after a prolonged period of having no insurance. Many of these patients were unable to afford preventive screenings or recommended medications. The setting for healthcare was typically a private physician’s office with the encounter being documented on a paper chart with little focus on diagnostic coding. The reimbursement for the majority of the visits would be based purely on the volume and thoroughness of each visit as indicated by the Current Procedural Terminology (CPT) code.
Although there have been some shifts in these practices in recent years, such as by incentivizing use of electronic health records (EHRs), more substantial changes will occur in 2014. At that time, physician–patient interactions will be much more likely to occur with geriatric care providers operating within an integrated delivery network or similarly organized group. The encounter, if with a new Medicare beneficiary, will likely be a continuation of care already being rendered because that individual will have had coverage prior to obtaining Medicare. The visit will be heavily focused on preventive care with careful documentation in an EHR and detailed coding of every diagnosis. This visit will be reimbursed to the parent organization and, to a lesser extent, the salaried provider, based on achievement of accountable outcomes, such as reductions in glycated hemoglobin, low-density lipoprotein levels, and blood pressure.
Again, these changes are occurring primarily due to the changes put in place by the ACA through an expansion of insurance, adjustments in reimbursement, and subsequent changes to care delivery. To understand how best to prepare for these changes, this article examines each of these topics in greater detail.
Insurance Expansion
The essence of the ACA is the insurance expansion through the new Health Insurance Marketplace (HIM)2 and Medicaid to effectively provide affordable coverage for many of the 55 million Americans who are currently uninsured or underinsured (Table 1). Since October 2013, individuals who have been able to get through to the government Website www.healthcare.gov have been able to evaluate available plans, with open enrollment currently scheduled through the end of March 2014. The objective of HIM is to simplify the search for health insurance by gathering all options in one place. Many individuals will have access to free or low-cost insurance programs or a new kind of tax credit that lowers monthly premiums. All health insurance plans in HIM must present their price and benefit information in easy-to-understand terms.
One critical point to remember is that HIM plans are not available to Medicare beneficiaries. To reinforce the message, the 2014 Medicare & You handbook from the Centers for Medicare & Medicaid Services (CMS) contains a prominent notice: “The Health Insurance Marketplace, a key part of the ACA, will take effect in 2014. It’s a new way for individuals, families, and employees of small businesses to get health insurance. Medicare isn’t part of the Marketplace.”3
In addition to HIM plans, Medicaid eligibility limits in participating states will be increased beginning in January 2014, so that adults earning up to 138% of the federal poverty level will be eligible for benefits.4 For a single person, that is an annual income of $15,856. This change is expected to decrease the number of uninsured by several million individuals. While these two expansions of insurance offerings may not seem relevant to geriatric care providers, this modification will eventually affect them. In the past, many uninsured individuals may have deferred preventive care prior to entering the Medicare system, creating a burden with a “backlog” of ailments that needed treatment. The current thinking is that, with ACA in place, those entering Medicare in subsequent years will present with better health as a result of earlier access to health insurance.
Within Medicare, there are some continued changes to the program, including expanding benefits for beneficiaries; specifically, the Medicare Part D coverage gap will continue to be filled in.5 This expansion started in 2012, with a required pharmaceutical rebate of 50%; over the course of the next several years, an additional 25% will be filled in, leaving Medicare beneficiaries with just 25% out-of-pocket (OOP) costs for their prescriptions. It is incorrect to describe the coverage gap as being completely filled in; rather, the Medicare beneficiary OOP during the coverage gap (also known as the “donut hole”) will be 25%, the same as their OOP during the initial benefit phase that precedes the coverage gap. While this closure started in 2012 and will occur slowly through 2019, it should decrease nonadherence to medications caused by high patient OOP costs.
Also gaining use in 2014 will likely be Medicare’s improved preventive initiatives, such as no patient copayments for screenings recommended with a grade of A or B by the US Preventive Services Task Force6 as well as more comprehensive annual wellness examinations, all of which are aimed at earlier detection and treatment. All of these interventions that in the past had been delayed by patients because of high OOP expenditures should improve the health of Medicare beneficiaries.
Reimbursement Changes
Changes in how geriatric care providers are paid will continue, if not accelerate, as we move into 2014 (Table 2). Under fee-for-service (FFS), Medicare adjustment will come under the Sustainable Growth Rate (SGR) formula.7 The SGR was set to go into effect on January 1, 2013, which would have resulted in a 26.5% cut in physician rates. The passing of the American Taxpayer Relief Act in January 2013 delayed SGR implementation for another year and maintained physician payments at their current rates through December 31, 2013. It is unclear at this time whether the SGR will be adjusted or eliminated, as outlined in the Medicare Patient Access and Quality Improvement Act of 2013.8
On July 30, 2013, the House Committee on Energy and Commerce approved the Medicare Patient Access and Quality Improvement Act of 2013,8 with several amendments. As of September, the bill had been referred to the Subcommittee on the Constitution and Civil Justice. If signed into law, the Act would repeal the SGR, effective 2014, and set annual updates at 0.5% for 2014 and beyond. Medicare spending for physician services would be reduced by up to 1% in 2016 to 2018 to account for “misvalued services” to be identified by a new entity. Starting in 2019, Medicare’s payment rates would be based on physicians’ performances in the Quality Update Incentive Program, which the bill would create, and result in either payment penalties or incentive payments. Scheduled penalties under current regulations would remain, such as the Value-Based Modifier, Physician Quality Reporting System, and EHR Incentive Programs. The bill would require new procedure codes and payments for complex chronic care coordination services by physicians, physician assistants, and nurse practitioners. It would also alter Medicare payments in some metropolitan areas of California, and it would establish procedures and an authority to evaluate and implement new alternative payment models nationally.
In addition, the bill would create a new physician reporting system to “improve the accuracy of relative values,” such as data relating to service volume and time and would incorporate existing data of physician quality, patient scheduling systems, and cost accounting systems, among other things.8 The bill would establish incentivizing mechanisms for physicians across specialties and settings to report these data. To fund this system, one million dollars would go from the Federal Supplementary Medical Insurance Trust Fund (“Medicare Trust Fund,” for Parts B and D) to the CMS Program Management Account every fiscal year.
For fee schedules established for 2016, 2017, and 2018, the Secretary of Health and Human Services would have to identify “misvalued services” based upon data from the physician reporting system and other sources. The identified services would need to result in relative value adjustments creating a reduction in spending of up to 1%.8 This spending reduction would not be subject to budget neutrality. These funds would be removed from the pool of spending for Medicare physician services.
Beyond the SGR and FFS reimbursement, CMS, through its Centers for Medicare & Medicaid Innovations (CMMI) is testing value-based purchasing models that will force geriatric care providers to deliver outcomes for which they are held accountable. Many providers will experience this accountability most strongly if they practice within an Accountable Care Organization (ACO). As described by CMMI, an ACO is a group of physicians, hospitals, and other healthcare providers who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve.9
Coordinated care helps ensure that patients, especially those who are chronically ill, get the right care at the right time, with the goals of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and in spending healthcare dollars more wisely, it will share in the savings it achieves for the Medicare program.
In addition, physicians and other healthcare professionals will be affected as managed care organizations focus even more on achieving high thresholds for quality measures under the CMS Five-Star Quality Rating System. To encourage Medicare Advantage (MA) plans to provide quality care, the ACA authorized Medicare, beginning in 2012, to pay bonuses to MA plans if they receive four or five stars (indicating above average or excellent performance, respectively) on the program’s Five-Star Quality Reporting System. The ratings are based on how well plans do on more than 50 performance measures. Building on that provision, CMS expanded the reach of this program, enabling a bonus to be awarded to plans that achieve a three-star rating or higher; as more plans can receive bonuses and the size of the bonuses may be increased, this program provides an incentive for plans to maintain high ratings or improve their ratings.10
As providers look to determine which organizations to join, most will benefit by beginning to work at increasing their patient volumes—in essence, managing more patients of more significant market presences. With more patients living longer due to expanded access to healthcare and better quality overall, physicians and other healthcare professionals will then need to demonstrate their ability to improve the efficiency and effectiveness of care delivery. With larger numbers of patients and attractive care delivery models, providers will be in a stronger position to choose a partner with whom to collaborate, although the exact partner, timing of arrangement, and structure will need to be carefully considered. These partners will be critical from a contracting and operational standpoint because of the increasing complexity of performance measures and reimbursement pressures.
In addition to these models of care, CMMI is also shifting from FFS to bundled payment approaches. On January 31, 2013, CMS announced the healthcare organizations selected to participate in the new payment model called Bundled Payments for Care Improvement (BPCI) initiative. The BPCI is comprised of four broad models under which organizations will enter into payment organizations that include financial and performance accountability for episodes of care.11 The goal of BPCI is to improve coordinated, quality care at a lower cost to Medicare.
The national focus on reducing readmissions rate will also indirectly impact geriatric care providers. Section 3025 of the ACA established the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to hospitals with excessive readmissions; this is defined as admission to a hospital within 30 days of a discharge from the same or another hospital.12 The program, which went into effect on October 1, 2012, has already trickled down to geriatric care providers, requiring them to play a thoughtful role in care transitions to reduce avoidable readmissions for acute myocardial infarction, heart failure, and pneumonia. In 2015, CMS will add to this list patients admitted for an acute exacerbation of chronic obstructive pulmonary disease, elective total hip arthroplasty, and total knee arthroplasty.12
These changes in reimbursement are likely to result in a reduction in reimbursement for geriatric care providers, although those who are able to deliver the outcomes for which they are being held accountable will be rewarded. Those who remain focused on the more traditional volume-based FFS arrangement will begin to feel the market moving away from them.
Delivery Systems
Lastly, the shift in delivering care in the most efficient and effective manner is being imposed via regulation and financial penalties for failure to move in this direction, as in the use of EHRs (Table 3). The Medicare and Medicaid EHR Incentive Programs provide incentive payments as geriatric care providers adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology.13Meaningful use is defined as a set of core and menu standards defined by CMS to govern the use of EHRs; by meeting the specified criteria, eligible professionals, hospitals, and critical access hospitals can receive incentive payments.14 Eligible professionals can receive up to $44,000 through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program. Unfortunately, incentive payments made through the Medicare EHR Incentive Program are subject to the mandatory reductions in federal spending known as sequestration, which is required by the Budget Control Act of 2011.13 Under these mandatory reductions, Medicare EHR incentive payments made to eligible providers have been reduced by 2% since April 1, 2013.
Physicians working in long-term care (LTC) and post-acute care settings have not been eligible to participate in the EHR programs. But beginning in 2014, providers of patients receiving LTC and post-acute care services may be required to send care summary records during transitions of care.15 That means that as EHR adoption becomes more ubiquitous in other healthcare settings, LTC and post-acute care providers may eventually need to adopt EHRs to keep up with the exchange of standardized clinical data across care settings.16 CMS recently lifted the exemption that precluded the electronic transmission of prescriptions (e-prescribing) to LTC facilities, thereby requiring facilities to adhere to the e-prescribing standards set by the National Council for Prescription Drug Programs starting November 1, 2014.17 This deadline means LTC physicians will soon be eligible for both the incentives and penalties in meeting criteria of meaningful use. According to CMS, eligible professionals who are not demonstrating meaningful use of EHRs will be subject to payment adjustments beginning on January 1, 2015.18 The adjustment is 1% per year and is cumulative for every year that the professional is not a meaningful user.18
While many of these changes in care delivery in 2014 are simply continuations of initiatives already in place, there is one that stands on its own on the 2014 calendar: October 1, 2014, which is the date currently set for the start of coding using the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10). Its predecessor, the ICD-9, has been used widely in the United States since 1978. The ICD-10 will update the codes that are used to report medical diagnoses and inpatient procedures. The transition is required by all providers covered by the Health Insurance Portability and Accountability Act.19 While the changes to the ICD-10 are significant, the CPT and Healthcare Common Procedure Coding System will continue to be the code sets for reporting ambulatory procedures.
The changes in the ICD-10 are intended to generate more specific data that can better identify diagnosis trends, public health needs, epidemic outbreaks, and bioterrorism events.20 The number of diagnosis codes in the ICD-10 is expected to be about 68,000, compared with 14,000 codes in the ICD-9. By having precise codes that more accurately reflect current medical knowledge, the hope is that there will be fewer rejected claims and improvements in benchmarking data, quality and care management, and public health reporting.20
Healthcare providers should prepare for these changes, as updating all administrative transactions with the ICD-10 codes will likely be a complicated process, with provider’s encounter forms or “superbills” becoming longer and more complicated. Other systems and work processes that will likely need to be reviewed and updated include practice management systems, quality reporting systems, EHRs, and contracts.20
Conclusion
For many geriatric healthcare providers, 2014 may represent a shift from a traditional individual provider or small group private practice to a larger group or integrated delivery network. For all healthcare providers, it will mean a greater focus on outcomes for which they will now be accountable. In the end, 2014 will see an acceleration of the changes shaping the healthcare environment. Some of these changes may significantly improve care for older adults. How geriatric care providers are judged will be based—at least in part—on their ability to adjust and successfully adapt to this changing environment.
References
1. The Patient Protection and Affordable Care Act, HR 3590, 111th Cong, 2nd Sess (2010). www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf. Accessed October 10, 2013.
2. What is the Health Insurance Marketplace? Healthcare.gov Website. www.healthcare.gov/what-is-the-health-insurance-marketplace. Accessed October 10, 2013.
3. Centers for Medicare & Medicaid Services. Medicare & You. Baltimore, MD: US Department of Health and Human Services, 2013. www.medicare.gov/Pubs/pdf/10050.pdf.
4. Eligibility. Medicaid.gov Website. www.medicaid.gov/AffordableCareAct/Provisions/Eligibility.html. Accessed October 10, 2013.
5. Closing the coverage gap—Medicare prescription drugs are becoming more affordable. Medicare.gov Website. www.medicare.gov/Pubs/pdf/11493.pdf. Accessed October 10, 2013.
6. USPSTF A and B recommendations. US Preventive Services Task Force Website. www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm. Accessed October 10, 2013.
7. Estimated sustainable growth rate and conversion factor for Medicare payments to physicians in 2013. Centers for Medicare & Medicaid Services Website. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesC.... Accessed October 10, 2013.
8. Medicare Patient Access and Quality Improvement Act of 2013, HR 2810, 113th Cong, 1st Sess (2013). https://docs.house.gov/meetings/IF/IF00/20130730/101240/BILLS-113HR2810ih.... Accessed November 18, 2013.
9. Accountable Care Organizations (ACOs): general information. Centers for Medicare & Medicaid Services Website. https://innovation.cms.gov/initiatives/aco. Accessed November 12, 2013.
10. Medicare advantage plan star ratings and bonus payments in 2012. Henry J. Kaiser Family Foundation Website. https://kff.org/medicare/report/medicare-advantage-2012-star-ratings-and-.... Published November 1, 2011. Accessed November 22, 2013.
11. Bundled Payments for Care Improvement Initiative [news release]. Baltimore, MD: Centers for Medicare & Medicaid Services; September 30, 2013. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-I.... Accessed November 12, 2013.
12. Readmissions reduction program. Centers for Medicare & Medicaid Services Website. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/.... Updated August 2, 2013. Accessed October 10, 2013.
13. EHR incentive programs. Centers for Medicare & Medicaid Services Website. www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/in.... Updated June 26, 2013. Accessed October 10, 2013.
14. Meaningful use. HealthIT Website. www.healthit.gov/policy-researchers-implementers/meaningful-use. Accessed November 13, 2013.
15. The Office of the National Coordinator for Health Information Technology. Health IT in Long-Term Care and Post-Acute Care Issue Brief. www.healthit.govhttps://s3.amazonaws.com/HMP/hmp_ln/imported/pdf/HIT_LTPAC_IssueBrief031513.pdf. Published March 15, 2013. Accessed November 22, 2013.
16. Long-term & post-acute care. HealthIT Website. www.healthit.gov/policy-researchers-implementers/long-term-post-acute-care. Accessed November 22, 2013.
17. Changes to Medicare e-prescribing program and part D e-prescribing standards. American Medical Association Website. www.ama-assn.org/resources/doc/washington/medicare-e-prescribing-changes.... Accessed November 22, 2013.
18. Payment adjustments & hardship exceptions tipsheet for eligible professionals. Centers for Medicare & Medicaid Services Website. www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Do.... Updated October 2013. Accessed November 22, 2013.
19. ICD-10. US Centers for Medicare & Medicaid Website. www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10. Updated September 9, 2013. Accessed October 10, 2013.
20. Preparing for the conversion from ICD-9 to ICD-10: what you need to be doing today. American Medical Association Website. www.ama-assn.org/resources/doc/washington/preparing-for-the-conversion-f.... Updated September 25, 2012. Accessed November 22, 2013.
